Provider Demographics
NPI:1508004185
Name:LONGO, KATHLEEN ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:LONGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 AVENUE J
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-2209
Mailing Address - Country:US
Mailing Address - Phone:732-521-2949
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF335344OtherLICENSE NUMBER